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VOL.13 NO.

6 JUNE 2008

Medical Bulletin

Doctors and Stress


Dr. Josephine GWS Wong
MBBS, MA, MRCPsych, FHKCPsych, FHKAM (Psychiatry)
Specialist in Psychiatry

Dr. Josephine GWS Wong

Introduction
It is well-known that being a doctor is stressful.
Previous studies have shown a higher level of stress
amongst doctors when compared to the general
population. Firth-Cozens1 noted that the proportion of
doctors showing above threshold levels of stress is
around 28%, in cross-sectional and longitudinal
studies, compared to around 18% in the general
working population. There is also evidence to show an
increased rate of psychological morbidity, for example,
depression, anxiety and substance abuse amongst
doctors. Local data are still limited, but there is
preliminary evidence to suggest elevated anxiety,
depression and stress in Hong Kong medical students 2
and interns (unpublished data). Rates of stress are
elevated in all doctors, regardless of the setting in
which they work, but junior doctors and female
doctors are particularly at risk. As doctors, we are
accustomed to identifying stress in our patients. We
inform them about health consequences of excess
stress and advise them on lifestyle changes and
relaxation. The pathology is usually in others, in
patients we look after. Are we then able to identify
stress in ourselves, manage our stress in an adaptive
manner and seek help when such stress becomes too
much to handle?

Transactional Model of Stress


Before we go further, it is important to understand
what stress is. The transactional model of stress by
Lazarus & Folkman 3 conceptualises stress as resulting
from an imbalance between demands and resources,
or as occurring when pressure exceeds one's perceived
ability to cope. Therefore, what appears stressful to
one person may be a welcome challenge or all-in-aday's-work for someone else. More importantly, the
transactional model introduces room for intervention.
Stress can be reduced by enhancing the individual's
resources, for example by helping people change their
perception of stressors and by enabling them to cope
and improve their confidence in their ability to do so.
In addition, the demand can also be modified, for
example by increasing its predictability and
controllability through contingency planning, training
and risk management. Primary and secondary
prevention strategies are valuable interventions that
modify the stress itself and response to stress. These
will be discussed in detail later in the paper.

Sources of Stress
The sources of stress in medical practitioners vary with

the type of medical practice (private vs. public, hospitalbased vs. community-based) and specialty. There are
many potential sources of stress that relate to the job, the
organisation, the doctor himself/herself, work-life
balance and relationships with other people (see Box 1).
Usually, a number of these factors are present in an
individual doctor, and therefore the difficulties faced by
the doctor are compounded and complicated.
In addition, there is an apparent mismatch between what
doctors are trained for and what they are required to do.
For example, in the medical curriculum, there is much
focus on patho-physiology, diagnosis and treatment.
There is now increasing emphasis on communication
skills, law and ethics in medical education. However,
other key aspects of a doctor's job like administrative and
financial management are poorly addressed, and these
often cause stress amongst doctors.
Box 1 Sources of Stress for medical practitioners
The job
Workload
Time pressure
Administrative duties
Sleep deprivation
No regular meals
Threat of malpractice suits
The organisation
Career structure
Career uncertainties
Inadequacy of resources and staff
Lack of senior support
Culture and climate of the organisation
The doctor
Personality (e.g. perfectionistic, Type A)
High demands on self and others
Dealing with death and dying
Confrontation with emotional and physical suffering
Relationships with other people
Staff conflicts
Bullying
Professional isolation
Patient's expectations and demands
Level of support from friends and family
Work-life balance
Stress over-spill from work to home and vice versa
Lack of exercise and other leisure activities
Lack of free time
Home demands
Disruptions to social life

Consequences of Stress in Doctors


Physical complications of increased stress are wellknown. These include: insomnia, gastrointestinal
disturbance, tension headaches, hypertension, fatigue,
lowered immunity, menstrual irregularities and sexual

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dysfunction. Adverse effects of stress may affect not


only the individual doctor, but also his/her family life,
marriage and social life. Furthermore, stress is
associated with burnout 4,5 (Box 2) in which 'what
started out as important, meaningful and challenging
work becomes unpleasant, unfulfilling and
meaningless. Energy turns into exhaustion,
involvement turns into cynicism and efficacy turns into
ineffectiveness'. Burnout has been shown to be
associated with increased depression and physical
illness, notably musculoskeletal disorders in women
and cardiovascular disorders in men. Burnout is also
associated with an increase in malpractice suits to the
extent that American insurance carriers are sponsoring
stress reduction seminars as a liability prevention
strategy6. Emotional exhaustion and detachment can
fundamentally change a doctor's perception of the
doctor-patient relationship, and can also affect
interactions with family members. Stress also leads to
increased rates of minor and major psychiatric illness,
including mood disorders, anxiety disorders, substance
abuse. As a result of stress, quality of patient care may
be compromised and medical errors may increase7.
Box 2 Burnout
Components of burnout (Maslach et al, 2001):
(1) Emotional exhaustion: feeling emotionally drained by
one's contact with other people, lack of replenishment,
unable to face another day or another person in need
(individual stress dimension of burnout)
(2) Depersonalisation/ cynicism: negative feelings and
cynical attitudes towards the recipients of one's service
of care, can turn to dehumanisation (interpersonal
dimension of burnout)
(3) Reduced personal accomplishment: a decline in feelings
of competence and productivity at work, growing sense
of inadequacy about ability to help others, may result in
self-imposed verdict of failure (self-evaluation
dimension of burnout)
Warning signs of burnout
Chronic fatigue - exhaustion, tiredness, a sense of being
physically run down
Anger at those making demands
Self-criticism for putting up with the demands
Cynicism, negativity, and irritability
A sense of being besieged
Exploding easily at seemingly inconsequential things
Frequent headaches and gastrointestinal disturbances
Weight loss or gain
Sleeplessness and depression
Shortness of breath
Suspiciousness
Feelings of helplessness
Increased degree of risk taking

Medical Bulletin
wishful thinking and emotional distancing, but these do
not work long term. Doctors are also 'poor' patients due
to maladaptive health behaviours 9,10 like selfmedication, not seeking a formal medical consultation
when ill and continuing to work when unwell. Most
doctors do not have their own general practitioner.
Some doctors regard falling ill as shameful, especially
when the illness is psychological in nature. Some think
that they should always be able to master and control
their emotions and it is a sign of weakness when they
experience emotional distress. There are also concerns
about being stigmatised by fellow doctors or being
discriminated against in their career development if
they are in the mental health system.
These attitudes reflect widespread stigma towards
mental illness in the general population and within the
medical profession11.

What Can We Do About This?


Prevention is Better than Cure
Stress is inevitable, but it is mismanaged stress that is
damaging in its consequences. There is now much
attention on measures that promote mental health and
wellbeing in medical students and doctors, and
prevention of stress-related morbidity. In considering
preventative measures, it is important to address both
primary and secondary prevention. Primary prevention
aims to enhance mental health literacy and psychological
wellbeing generally, in the population in question (in this
case, doctors and medical students). This might include
workshops on time management, stress management,
mindfulness-based stress reduction, coping skills
training, relaxation training, etc. Secondary prevention
measures target the 'at risk' group such that help and
support can be provided in a timely and proactive
manner, to prevent further deterioration and
impairment. Doctors themselves also have a role to play
in looking after their own mental health and managing
stress. Self help strategies are often adequate without
having to seek outside assistance (Box 3).

Examples of Services Available


Below are examples (not an exhaustive list) that illustrate
primary and secondary prevention resources currently
available to medical students and practising doctors.

Medical Students
Barriers to Care
Despite the high prevalence of stress in doctors, and a
myriad of physical and mental health consequences,
doctors are notoriously reluctant to seek help for
themselves8. The subjective experience of being ill is not
taught or much discussed at medical school. Doctors are
often perfectionistic, self-sacrificing people with high
levels of personal drive and altruism. This predisposes
them to put others' needs before their own, thus
increasing stress but their personality also makes it hard
for doctors to self-reflect or to seek help. For most
doctors, stress or illness is what happens to other
people, and doctors are there to help them get better. It
is sometimes very difficult for doctors to acknowledge
their own stress and distress, and even more difficult to
acknowledge that their work performance is affected as
a result. Some doctors deal with stress by engaging in

There are good reasons for starting prevention work in


medical school. Medical students are our future doctors.
Medical education is in itself a stressful process. A
previous study found elevated depression, anxiety and
stress in local medical students2. Students' mental health
(or rather the lack of it) affects their academic attainment,
social life, and the quality of service they provide to the
community as future doctors. Moreover, their own
mental distress may influence the way they perceive
mental health and help-seeking in the care of their future
patients. In a 2003 Royal College of Psychiatrists Report12,
it outlined a key responsibility of medical schools to
ensure that their graduates are (1) aware of their personal
and professional limitations; (2) willing to seek help
when necessary; and (3) aware of the importance of their
own health, and mental health and its impact on their
ability to practise as a doctor.

Medical Bulletin
One example of resources within medical school that
address psychological wellbeing of the student body is
the Programme for Effective Transition and Student
Support (PETSS) at the medical faculty of the University
of Hong Kong13. PETSS aims to promote mental health
literacy, with student support services and activities to
develop leadership within the student body. There are
primary prevention activities that aim to enhance mental
health awareness and resilience in medical students e.g.
an educational website on mental health issues designed
by medical students in a Mental Health Support Group14,
workshops on time management, study skills,
mindfulness-based stress reduction, emotional and social
competence, etc. In addition, there is a buddy scheme in
which Year 1 students are mentored by more senior
medical students to help them adapt to life in university.
Secondary prevention strategies that aim at helping 'at
risk' medical students include the establishment of a
Wellbeing Committee that consists of a group of
volunteer teachers who provide support and counselling
to students in need. The issues that students bring to the
Wellbeing Committee include emotional problems,
relationship issues, study difficulties, doubts about
commitment to the course, etc. In addition, the Mental
Health Support Group14, a pioneering student-initiated
peer support network for fellow medical students runs a
discussion forum and offers email counselling for
individuals. Mental Health Support Group members are
trained in Mental Health First Aid and basic counselling
such that they can respond appropriately if they come
across students in distress. Preliminary evaluation
suggests that MSG services are welcomed by medical
students. These are specific services for medical students.
Students can also access generic support services
provided by the university itself through its health
service or counselling centre.

Practising Doctors
For practising doctors, organisational and occupational
changes such as increasing support for staff, reducing
non-medical workload, and reducing working hours are
all likely to reduce mental stress in doctors. The
establishment of Oasis15 at the Hospital Authority in 2002
was one example of how primary prevention can be
initiated by an employer. Oasis, Centre for Personal
Growth and Crisis Intervention, aims to promote a
culture of care within the Hospital Authority. It organises
primary prevention activities to enhance staff members'
ability to develop and mobilise their own inner resources
to overcome life's difficulties. There are educational talks,
workshops (for example on resilience training, life
education) and quiet rooms which provide an
environment in which to meditate and have time to
oneself. There is also training of critical incident
management teams in each hospital in order to facilitate
and coordinate timely staff support in case of a crisis, for
example suicide of a colleague or a serious medical error.
In addition, Oasis also provides treatment by clinical
psychologists for health care workers (including doctors)
who are at risk or already impaired, in a safe and
confidential setting away from their usual workplace.
It is heartening to see that seeds appear to be sowed for a
culture change within the medical profession such that
high stress is acknowledged and taking steps to enhance
one's own mental health is no longer embarrassing or

VOL.13 NO.6 JUNE 2008

burdensome. There is an increasing recognition that we


need to 'care for the carers'. However, there is still room
for improvement since services for doctors working
outside the Hospital Authority is still lacking. For doctors
under stress and in distress, it is important that they feel
able to seek help and advice from a service that is
confidential, accepting and accessible.

Ethical Issues in Treating Doctors as


Patients
While primary and secondary prevention strategies are
important, there will always be doctors whose
psychological distress becomes so severe that clinical
intervention becomes necessary. Although the ethical
duties owed to a doctor-patient is the same as those to a
member of the general public, there are unique
challenges in treating doctors as patients and in
establishing a therapeutic alliance8. As outlined earlier,
there are barriers to a doctor seeking help for
psychological distress. Sometimes, a doctor-patient may
be unaware of or unwilling to accept the severity of
his/her mental difficulties. In some situations, issues arise
regarding the fitness of a doctor-patient to practise
medicine. These present a difficult dilemma for the
treating doctor as there is a conflict between his/her
loyalties to a doctor-patient and his/her duty to report a
doctor who may pose a risk to patient safety. Any
disclosure of concerns about patient safety would affect
the livelihood of the doctor-patient, and may result in
suspiciousness and anger within the therapeutic
relationship, with minimisation of symptoms, distress
and functional impairment. The relationship between the
treating doctor and the doctor-patient can turn from
what should be supportive to adversarial. Whilst this
dilemma is similar to other situations in which patient
confidentiality conflicts with public safety, the treating
doctor may find this particularly difficult because the
doctor-patient is a colleague. The best approach would
be one of frankness and open discussion about the
treating doctor's concerns. It is likely that the doctorpatient would opt for voluntary sick leave or a
temporary withdrawal from frontline clinical service,
rather than making it necessary for the treating doctor to
report him/her to the licensing authority.

Reflections and Conclusions


Being a doctor is physically and emotionally demanding.
There is good evidence to show that doctors are at higher
risk of stress than the general population. There needs to
be a culture change within the profession for doctors and
their employers to pay closer attention to how doctors
deal with the demands of the job, how they look after
their own mental health and attain wellbeing and a sense
of balance between their working and personal lives.
Doctors are expected to be conscientious, compassionate
and self-sacrificing. However, we must remember that
doctors need to nurture themselves, address their own
spiritual needs and engage in self-care practices, in order
to be able to give their best to patients.
Peer support and a sense of community are important.
Sometimes, doctors feel that their problems cannot be
understood by people outside of the profession, therefore
developing and maintaining a professional network is
valuable. Some private doctors work in a single-handed

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practice, thus adding to a sense of professional isolation.


Hong Kong may need to follow in the footsteps of other
countries e.g. Australia16 and Britain17 in developing
multi-faceted support services for doctors under stress.
We quote a wise and insightful comment from FirthCozens 'Getting things right for patients means first
getting things as good we can for those who deliver
their care.' We look forward to further discussions
about how psychological wellbeing of doctors in Hong
Kong can be promoted.
Box 3 Self help
Doctors can help themselves to reduce the impact of stress and
avoid burnout or other psychological morbidity.
(1) Identify the most important sources of stress in your life
(2) Time management: enhances doctor's sense of control,
increased productivity, reduces overload strain therefore
reduces anxiety.
(3) Managing political and people problems: make sure you
give enough time to the people that matter, keep a distance
from people who drain you of emotional energy, seek
social support
(4) Avoid exhaustion: make sure you get enough rest, take a
break from time to time, engage in a leisure activity,
exercise regularly, have a healthy diet
(5) Protect the meaning of your job: manage your workload,
focus on aspects of your job that gives you satisfaction,
delegate when you can, learn to say no
(6) Maintain a good work-life balance
(7) Do not expect perfection
(8) Learn relaxation techniques
(9) Don't sweat the small stuff!

Medical Bulletin
References
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